Nearly every state’s legislature begins their 2014 session this month. So January is the appropriate month to offer my five point agenda for nursing home reform. I believe that these five points can, at a reasonable cost to taxpayers and to nursing homes, help improve the quality of the care provided to residents.

Suggestion #1: Have each state mandate an INCREASE in the percentage of inspections (commonly referred to as “surveys’) that MUST take place outside of regular business hours on weekdays. This standard should apply to both annual inspections (inspections the state conducts approximately once each year at all licensed nursing homes) as well as to surprise inspections (these are inspections that take place in response to complaints the state receives about a particular nursing home.

In most states a minimum of 10% of nursing home annual inspections must begin at night or on the weekend. That means that 90% of inspections are likely done during 23% of time that accounts for regular weekday business hours. I believe that if state law would mandate a minimum of 25% – 33% of inspections begin on weekends and during hours when administrators are not normally at work the inspectors would get a more accurate view of the low quality of care that goes on in nursing homes on weekends, 2nd and 3rd shift and on holidays — the times when administrators are rarely on the job.

As a family member of a nursing home resident, it was “after hours” that my mother experienced the worst neglect by her caregivers. These are the hours when staffing levels are usually at their lowest and when management isn’t present to see for themselves what’s going on.

Suggestion #2: Require management personnel to work staggered shits ALL THE TIME, not just when state inspectors are in their building. In large facilities that have an Assistant Administrator (or equivalent position), the state should mandate that the Administrator and their assistant must not be allowed to work identical shifts. I believe the state should require that the shifts for management can not overlap more than four hours per day (Example: Administrator works 8:00am – 4:30pm, while the Assistant Administrator is scheduled to work 12:30pm – 9:00pm).

The majority of nursing homes are too small to be able to afford an Assistant Administrator. Yet even these facilities MUST have a full-time Director of Nursing on staff. In these nursing homes the same “staggered shifts” rule should be in place for the Administrator and Director of Nursing.

Why suggest this legislative mandate? For much of the same reason that I made my first suggestion: after management is out of the building the quality of care given often suffers. As the cliche goes, “When the cat is away, the mouse will play!” And “play” they often do (e.g., taking excessive smoke breaks, ignoring call lights, talking on their personal cell phone instead of checking on or responding to their residents). One third shift nursing staff member at an Indiana facility where my mother lived admitted to me that she “preferred” to work overnight so “the big shots” couldn’t get in her way of doing her job the way she wanted to do it. Scary! One of CNAs who worked with this individual on third shift shared with me that this nurse took an average of seven (7) smoke breaks — OFF THE UNIT — PER HOUR! This clearly would not be allowed by either the state inspectors or sane nursing home management — but how could the state or management know this was problem existed if they aren’t in the building at at times other than when management is in the building? Residents with dementia are likely incapable of reporting such problems. Family members can’t stay with their loved one 24’7 non-stop to monitor the situations. Placement of a “Granny Cam” inside the room is incapable of documenting problems that take place outside of the resident’s rooms (example: documenting a lack of staffing at the nurse’s station caused by staff taking an excessive number of smoke breaks).

If it is impossible to have management in the building 24/7, then the state should mandate their presence a minimum of 12 hours per day on non-holiday weekdays and 4 hours (or more) per day on holidays and weekends.

Suggestion #3: When the state shows up for an any type of inspection (annual or in response to a complaint) the inspectors (a/k/a “surveyors”) should IMMEDIATELY seize payroll data (before it can be altered) to verify staffing levels for the 14 continuous days immediately prior to the inspection. With this information in hand, inspectors should have the legal authority to insist that while they are in the building that the staffing level can NOT exceed the average staffing level for the previous 14 days.

Why do I believe this issue requires a legislative intervention? Because calling in off-duty nursing staff during an inspection or even bringing in temporary employees is one of the biggest (and most deceptive) things nursing home management does to make it appear that resident needs are being taken care of in a timely and appropriate manner — when the reality is that they aren’t being responded to in either a timely and/or appropriate manner when the state inspectors are not around. “Putting on a show” for state inspectors should be against the law!Inspectors should see and judge the quality of care based on the REALITY of ACTUAL staffing levels.

Suggestion #4: Pass legislation that prohibits nursing homes from either outright banning or limiting visits of residents by their family and friends. Once nursing home staff identify a resident’s family member(s) or friend(s) as a “trouble maker” (e.g., that we really have the courage to report their facility to the state, as is our LEGAL RIGHT AND MORAL RESPONSIBILITY TO DO) then you can count on the facility to begin devising schemes to make it look appear that we are the bad guy, thus justifying prohibiting (or at least limiting) our visits. Some facilities have even limited visits from family and friends from taking place on the unit where the resident resides — allowing, for instance, visits to only take place in the lobby. This way family and friends can’t observe the substandard care the resident is receiving, thus preventing them from being able to observe (and thus report to the state) problems with care.

Attempts to prevent family and friends from visiting nursing home residents (when no harm is being caused to the resident as the result of the visit and when the resident wants to receive visits from such individuals) is clearly a violation of nursing home resident’s civil rights! We activists must get through to these corrupt nursing home owners and managers that their facility is the HOME of the resident and therefore the SAME rights of visitation residents had at their house, apartment on condo apply inside the nursing home facility! Strongly worded legislation is clearly the only hope we have to prevent nursing homes from taking their residents hostage!

Suggestion #5: We need legislation that will mandate increased fines against nursing homes that are found guilty of abusing resident’s rights, especially with regard to forcing residents to move to another facility. Many nursing home residents find themselves being forced out of their facility as retaliation against the resident or their family for sticking up for their rights. This type of abuse of resident’s rights must stop! It is truly a twisted, dysfunctional way of thinking when a nursing home’s only way of handling it’s problems is to punish their residents (or the resident’s family) by forcing the resident to leave their facility. How many residents must suffer “eviction” before a facility is finally forced to look inside itself and make the changes needed to resolve their real problems?

How can you help to make these five changes happen within the state where you reside? Contacting your state legislators would be a good start. Also request the support of your local or state Long-Term Care Ombudsman to help promote this reform agenda. If your area or state doesn’t have a nursing home reform organization then start one! I’ll be glad to help you start and promote such an organization.

I believe that together we CAN make meaningful, important and positive changes take place within the nursing home industry. While the industry clearly has the big bucks to spend on maintaining the status quo, we have more than enough individuals on our side to make change HAPPEN!

The for-profit nursing home industry is quick to claim that they can’t afford to hire more nursing staff (nurses or CNAs) in order to improve to the quality of nursing home care. What a total crock of nonsense! It is widely known that most executives of the major nursing home corporations (e.g., companies that own multiple dozens of facilities in multiple states) make annual salaries in excess of one million dollars (not to mention live in million dollar homes) so they obviously have PLENTY of money to hire additional nursing staff and still have lots of money leftover to pay nice dividends to their stockholders.

In Kentucky, Indiana and the other eleven stats that don’t have minimum staffing standards for nursing home in place, the nursing home industry cry babies…er, I mean their lobbyists, have state legislators fooled into believing their lie about being “too poor” to improve the quality of care. Fine. Let the industry continue to perpetuate the fraud that they can’t afford to make things better (at least for now, they are getting away with this deception), because in the meantime here are three things that CAN be done to improve the quality of nursing home care withOUT forcing the nursing home industry to significantly increase the cost of doing business. The only expense to the facilities would involve paying a “shift differential” to staff working outside of first shift hours.

Suggestion #1: Have each state mandate an INCREASE in the percentage of surprise inspections (more frequently known as “surveys’) that MUST take place outside of regular business hours on weekdays.

For example, in Indiana, I was told by a gentleman who works for the Indiana Board of Health that at least 10% of inspections each year must begin at night or on the weekend. That means that 90% of inspections are likely done during 23% of time that accounts for regular weekday business hours. Me thinks that mandating more like minimum of 25% – 33% of inspections should be required to begin on weekends and during hours when administrators are not normally at work.

Why suggest this change? Because as those of us who are family members of nursing home residents know only too well, the quality of care provided residents often goes downhill considerably when management isn’t around. For nursing staff who have an outstanding work ethic, this isn’t an issue. But for the caregivers who don’t really much care about their residents, many of us have witnessed the negative impact on care when management isn’t in the building.

When the greedy nursing home industry finally gets the message that the state CAN and WILL be showing up UNexpectedly more often then I believe we’ll see improved staffing levels on second and third shift and on weekends and holidays. These are the times that staffing is at it’s lowest level in most facilities — which means these are the times when the quality of care is at it’s lowest.

Suggestion #2: Require management personnel to work staggered shifts ALL THE TIME, not just when the state is in their building.

In large facilities that have an Assistant Administrator (or equivalent position), the state should mandate that the Administrator and their assistant must not be allowed to work identical shifts. In fact, I believe the state should require that the shifts for management can not overlap more than four hours per day (Example: Administrator works 8:00am – 4:30pm, while the Assistant Administrator is scheduled to work 12:30pm – 9:00pm).

The majority of facilities are too small to justify the existence of an Assistant Administrator — yet ALL nursing homes (regardless of their size) MUST have a Director of Nursing on staff. In these facilities then the same rule should be in place: staggered shifts must be scheduled for the Administrator and Director of Nursing.

Why suggest this change? For much of the same reason that we made the first suggestion: after management is out of the building the quality of care given often suffers. As the cliche goes, “When the cat is away, the mouse will play!” And “play” they often do (e.g., taking excessive smoke breaks, ignoring call lights, talking on their personal cell phone instead of checking on or responding to their residents). If it is impossible to have management in the building 24/7, then the least the state should mandate is their presence a minimum of 12 hours per day on non-holiday weekdays and 4 hours (or more) per day on holidays and weekends.

Suggestion #3: When the state shows up for an any kind of inspection (annual or in response to a complaint) the inspectors (a/k/a “surveyors”) should IMMEDIATELY seize payroll data to (before it can be altered) to verify staffing levels for the 14 continuous days immediately prior to the inspection AND insist that while they are in the building that NO additional staff can be called in.

Why suggest this change? Because calling in off-duty nursing staff during an inspection is one of the biggest (and most deceptive) things nursing home management does to make it appear to the state that resident needs are being taken care of in a timely and appropriate manner — when the reality is that they aren’t being responded to in either a timely and/or appropriate manner when the state folks aren’t around. “Putting on a show” for state inspectors should be against the law! Inspectors should see and inspect and judge the quality of care based on the REALITY of ACTUAL staffing levels.

How can we make these three changes happen in our corner of the world? Contacting your state legislators would be a good start. Contact your local or state Long-Term Care Ombudsman to find the contact information for the agency in your state that regulates and inspects nursing homes. And if your area or state doesn’t have a nursing home reform organization, start one!

Together we CAN make meaningful, important and positive changes take place within the nursing home industry. They clearly have the big bucks to spend on maintaining the status quo, but we have the numbers of individuals on our side to make change HAPPEN!